Healthcare Provider Details

I. General information

NPI: 1689201337
Provider Name (Legal Business Name): LISA KEBALO-WALKER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KNOLLCROFT RD
LYONS NJ
07939-5001
US

IV. Provider business mailing address

151 KNOLLCROFT RD
LYONS NJ
07939-5001
US

V. Phone/Fax

Practice location:
  • Phone: 732-259-6671
  • Fax:
Mailing address:
  • Phone: 732-259-6671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number26NJ01018400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number26NJ01018400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code163WC2100X
TaxonomyContinence Care Registered Nurse
License Number26NR11264700
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number26NR11264700
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code163WX1500X
TaxonomyOstomy Care Registered Nurse
License Number26NR11264700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: